Patient Consent Form - Influenza Vaccination printable pdf download

Patient consent form

Patient/Guardian

Surname:

First name:

Phone:

Date of birth:

NHI:

Ethnicity:

NZ European

Maori

Samoan

Cook Island Maori

Tongan

Niuean

Chinese⃝

Indian

Other (such as Dutch, Japanese, Tokelauan) Please state:

Name of guardian (if applicable):

Address:

Your doctor’s name / surgery address and postcode:

This form confirms that you have given your consent to have an influenza vaccination.

If any of the following apply to you then please advise your healthcare professional:

I am currently unwell with a high fever

I have had a previous severe response to an influenza vaccination

I have a history of a bleeding disorder

I have a severe allergy to eggs and / or any chicken products

Possible responses to influenza vaccination:

Influenza vaccination is usually well tolerated. Possible responses include redness, tenderness or hardness at

the injection site for a day or two; a mild fever, muscle aches or headache within the first two days. Rarely, an

allergic response can occur.

You should remain under observation to watch for an allergic response

for 20 minutes after your vaccination.

The influenza vaccine does not protect against other respiratory viruses such as the common cold. For

more information on the influenza vaccine please refer to the Consumer Medicine Information located at

The Ministry of Health keeps a record of influenza vaccination on the National Immunisation Register so that authorised health

professionals can find out what vaccinations have been given. It helps to monitor the population's protection against influenza.

If you do not want your vaccination recorded on the National Immunisation Register please advise your doctor, nurse or healthcare

professional.

I have read or have had explained to me information about influenza vaccination, and I have had a chance to ask questions that

were answered to my satisfaction. I believe I understand the benefits and risks of influenza vaccination. I understand getting

the vaccination is my choice. I agree to get the vaccination and that it is recommended that I wait here for 20 minutes after

my vaccination.

I consent to this information being given to my healthcare provider to update applicable records.

Signed:

Date:

Signed/Guardian (if applicable):

Relationship to the child/patient:

Vaccination record (for Clinic Use Only)

The influenza vaccine is a

Vaccine:

Administered: Left / Right Arm

prescription medicine. Talk to your

healthcare professional about the

Vaccine Batch Number:

Vaccinator:

benefits and possible risks.

Expiry Date:

Key reference material

Patient Consent Form - Influenza Vaccination

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